PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT This report is for improving overall Metro System Safety. It is intended to be for confidential use only. This report is prepared based on the information available to the author at the time of the report. The findings, conclusions and opinions expressed herein are subject to change based upon further investigation and analysis. SUMMARY OF FACTS RELATED TO THE TRAIN #706, (LRV 203-207) AND PEDESTRIAN ACCIDENT AT MAIN STREET AND MCGOWEN STREET, RED LINE, ON SUNDAY, NOVEMBER 1, 2015. DESCRIPTION OF OCCURRENCE On Sunday, November 1st, 2015 at 10:34PM, Train #706 (LRV #203S-207N) was traveling southbound on Main St. (Track #2) approaching McGowen St. intersection. A male pedestrian was running across McGowen St. westbound against the pedestrian signal and was struck by the approaching train. The pedestrian was pushed underneath LRV #203 and ended up near the ‘C’ truck as the train came to a complete stop. He was pronounced deceased at the scene by emergency personnel. INJURIES None FATALITIES The pedestrian, Julian Chad Edward, age 23, was declared deceased at the scene. PROPERTY DAMAGE LRV #203 suffered damage to the front coupler cover and the magnetic trip stop. Cost to repair: $3,764.94 STREET CHARACTERISTICS Main Street runs north and south with one lane of vehicular traffic in either direction with no parking on either side of the street. McGowen Street is a two-way street running east and west with two lanes for vehicular traffic in each direction with no parking on either side of the street. Vehicles may turn left or right off of McGowen onto Main Street. McGowen platform on the Redline is a split platform. The northbound platform is located north of McGowen Street and the southbound platform south of McGowen Street. TRACK CHARACTERISTICS The track at this area is level, tangent, and located at grade and embedded in concrete, with two tracks, running northbound and southbound. Authorized train speed at this location is 35 MPH. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT MAIN AND MCGOWEN Red Line Train #706 and Pedestrian 11/1/2015 Page 2 SPEED AND SIGNAL RESTRICTIONS Train movement through the intersection is governed by a Bar Signal Indicator on the south side of the intersection. Authorized train speed at this location is 35 MPH. ENVIRONMENTAL CONDITIONS The temperature was approximately 64° Fahrenheit, and weather conditions were overcast. The Tracks were slightly wet from earlier showers. CIRCUMSTANCES A post incident investigation was conducted with Operator #26683. The Operator stated in substance, but not verbatim that on Sunday November 1, 2015, at approximately 10:34PM, “Traveling southbound into McGowen Station at about 20MPH when a white male ran into the trackway in front of the train and contact was made while braking and using audible”. Data and video download from the LRV showed that Train #706 was traveling at 21MPH before the collision (attachment D). Videos taken from the northbound train #701 (LRV #334S-333N), which was stopped at McGowen northbound platform just prior to the accident, show the pedestrian on the east side sidewalk running southbound, crossed Track #1 against the “Do Not Walk” signal and was struck by Train #706 on Track #2. CAUSE This incident was caused by the pedestrian crossing the street when it’s not safe and against the pedestrian signal. CONTRIBUTING FACTORS According to the paddle (attachment A), the Operator of Train #706 departed the previous station (Downtown Transit Center) over two (2) minutes ahead of the schedule. The view of the pedestrian could have been obstructed by the northbound Train which was stopped at McGowen northbound platform at the time of the accident. Event recorder download from LRV #203 indicates that the gong was not applied as the train was passing that stopped train at the station. According to Rule #3133 in the METRORail Rulebook, the gong must be sounded when passing a train which is stopped or at a station. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT MAIN AND MCGOWEN Red Line Train #706 and Pedestrian 11/1/2015 Page 3 DRUG AND ALCOHOL TESTING The operator of Train #706 LRV#203-207 was drug tested due the incident meeting the requirements of the FTA threshold. The drug and alcohol test results were negative. ACTION TAKEN MPD established a perimeter around the scene and only authorized personnel were allowed access. Train #706, LRV 203-207, was removed from service and inspected by Rail Vehicle Maintenance. No defects were found to the train that would have contributed to the accident. Train #706 was off-loaded and passengers were directed to alternate service. Both tracks at this location were taken out of service for approximately 3 hours and 40 minutes. Trains were turned north to south at Wheeler station and south to north at Downtown Transit Center. A Bus Bridge was established between Wheeler and Downtown Transit Center Stations. System Safety observed the traffic and pedestrian signals at Main & McGowen after the accident. All signals appeared to be working normally at the time. The Medical Examiner arrived at the scene approximately 12:20 AM and cleared at approximately 2:00 AM. The Train was moved few feet back and forth and LRV #203 was lifted slightly to allow HFD Heavy Rescue personnel to remove the body of the deceased from underneath the train. The Train was operated out of service by a replacement Operator back to the ROC. The Trackway was washed by HFD. NTSB notified at 11:10PM and issued case #1132315. RECOMMENDATIONS The LRV-Pedestrian accident was ruled preventable by the Safety Department. The Operator did not comply with all METRORail Rules and Procedures. The Safety Department is requesting one day retraining. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT MAIN AND MCGOWEN Red Line Train #706 and Pedestrian 11/1/2015 Page 4 SYSTEM PERFORMANCE INVESTIGATION/TESTING Video and data downloads were taken from LRV 203. Data downloads showed the Train Operator traveling at 21 MPH at the time of the accident (attachment E). The Maximum Authorized Speed while passing an opposing train in a station, split platform is 20MPH. Videos taken from the platform CCTVs and from the northbound train #701 (LRV #334S-333N), which was stopped at McGowen northbound platform just prior to the accident, show the pedestrian on the east side sidewalk running southbound and crossing Track #1 against the “Do Not Walk” signal and was struck by Train #706 on Track #2. Based on the speed of the train (21MPH) at the time the pedestrian came into the operator view, the train was travelling at approximately 31 feet per second. At that speed, the stopping distance of the train on dry rail and with normal braking is roughly 81 - 108 feet depending on use of maximum brake or full service brake and with a margin of error of plus or minus 5 percent (see Attachments D). The download shows the Operator applied horn and shortly after applied Full Service Brake. For unknown reasons, Full Service brake was disengaged and applied again. The train came to a full stop at approximately 271 feet. The body of the deceased was dragged for approximately 129 feet. Train Operator #26683 was first hired by METRO as a part-time Bus Operator September 2013. He switched to Rail in July 2014 where he qualified as an LRT Operator on September 9, 2014. He completed his Defensive Driving Course on July 14, 2014. During his time as an LRT Operator he had been involved in 2 previous accidents; one of the two was while he was still a trainee. Both accidents were classified as non-preventable. The work hours for Operator #26683 were reviewed; his last day off before the accident was on October 12th, 2015. He worked nineteen (19) straight days with ten (10) hours rest before each shift (Attachment A), and a total of 62 hours the week prior to the accident. On November 1st, 2015 Operator #26683 was working run #70032/70022 (see Attachment A) reporting to the Station Office at 6:14PM. The first half of his run (#70032) consisted of two trips. The accident occurred on the second trip. The previous two days, October 30th and 31st, he worked 8 hours in the Yard. There were no special instructions for the area of Main and McGowen at the time of the incident (see Attachment C). Maintenance history for LRV 203 was reviewed from since it was delivered December 21st, 2012. LRV 203 had been involved in four (4) other minor accidents since it was placed in service; suffering only damage to front and side coupler skirts. Repairs had been made to the LRV after each accident and prior to its return to revenue service. No defects were found to the train that would have contributed to the accident. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT MAIN AND MCGOWEN Red Line Train #706 and Pedestrian 11/1/2015 Page 5 CORRECTIVE ACTION PLAN A corrective action plan is needed due the Operator not operating per METRORail Rules and Procedures. Refer to the Matrix on page for details. PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT MAIN AND MCGOWEN Red Line Train #706 and Pedestrian 11/1/2015 Page 6 INTERSECTION MAP X Bing Maps screenshot of the area The red X indicates the location of the accident PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT MAIN AND MCGOWEN Red Line Train #706 and Pedestrian 11/1/2015 Page 13 Mohammed Boukhriss, Rail Safety Manager Investigated By Walter Heinrich, Director of Safety Approved By PRIVILEGED & CONFIDENTIAL FINAL ACCIDENT REPORT Corrective Action Plan for LRV Pedestrian Accident November 1st, 2015 DATE 11/1/2015 SAFETY OFFICER LOCATION DEFICIENCY Mohammed Boukhriss Main and McGowen Failure to apply Gong passing a train which was stopped at a station CORRECTIVE ACTION RESPONSIBLE DEPARTMENT/ CONTACT PERSON COST DATE TO BE COMPLETED STATUS AND DATE VERIFICATION AND REMARKS Unknown Closed 3/9/2016 Operator received 24 hours re-training. Documentation placed in the accident folder Re-training Training Department/S. Richard N/A